The final medical year was by far one of the toughest years in my life. I remember the stressful days and sleepless nights very well.
When I was at a job interview last year, one of the questions which I was taken by surprise was ” what are your strengths and weaknesses?”
Strengths was very easy, I could give ten with my eyes closed. Weaknesses on the other hand, it was obvious I have never given that much thought to the topic before. And who likes to talk about their weaknesses anyways? Talking about other peoples weaknesses is probably most peoples daily digest but not our own.
One of my major ones would be ‘the desire to be and have everything perfect’. Most people would admit that could be a strength but in reality, when uncontrolled, the opposite is true.
When I was in primary school I remember creating and re-creating works of art given as homework, as I looked at my finished masterpiece and thought, nahh….and basically just threw it into the bin and started a fresh. Usually the piece that I brought to school was not one that I was happy with, it was just that time had run out.
So today, as I thought a group of final year medical students, the part of my job that I really love and would do for free, by the bedside, I thought to myself, I wish they could see the previous group of final year medical students I had the privilege of teaching, just last year.
Not more than nine months ago, I was working with another organization in another part of the country. Life was hectic but fulfilling. I would choose being busy over having nothing to do, anytime.
The average working day consisted of leaving home at 7am just as it was getting bright outside with Baby still fast asleep, I would dash out the door with a cup of tea and milk (no sugar), wheat bread with cheese. I’m not saying this is healthy or recommending the same to anyone, it was just what was convenient at that time.
Waze would show me the quickest route (there were several different options) and usually I would have parked my car at the car park next to Grand Seasons hotel at about 7.30am. Parking is RM6 per day, RM3 per entry and another RM3 for additional hours. If early when parking is ample I’d always choose to park under the shades at the very end.
Then I’d head up to the office which is on the 10th/11th floor of Grand Seasons Hotel. It’s always kind of scary because there’s not many people around that time, but we do have a guard, but still…
There I’d have another drink while doing paperwork – which is mainly admin plus planning for upcoming lessons.
During this time, the students are on the wards. Some of them come as early as 5am. I tell them to time themselves. Do not spend more than one hour clerking one patient.
Back then I was the clinical clerkship director for third year medical students, in a four year medical school graduate program. There was a bubble between the change of two fourth year clerkship directors so during that brief period, I was asked to teach the final years. And it was a rewarding experience to say the least.
Expectations for bedside teaching for third and final year students were of course different.
With the final year students, it was a small group of four students back then, we would go round the ward and see an average of 20 patients per day.
Since there were many medical schools using HKL as their teaching hospital, we were allocated ward 26, CCU and CRW as our ‘designated’ areas.
In general, ward 26 has 30 beds. It is divided into five ‘cubicles’. Each student will be allocated a bed, so in general, every patient on the ward is the responsibility of a particular student.
The cubicle in the middle, opposite the nurses station, is where the sicker patients are placed and hence these patients will be divided equally amongst the students. As the patients recover and await discharge, they are generally shifted away to the beds at the end of the room. The end away from the entrance however is reserved for patients who are infectious.
The first thing I would do as I enter the ward is observed whether any of the staff are wearing N95 masks. Then, I would check at the whiteboard to see the status of any TB positive patients. Then I’d ask my students. Most of the time, there are patient/s newly diagnosed with pulmonary TB in the ward. Students are instructed not to see these patients.
Teaching rounds start usually around 9-10am depending. With the final year students, we just started at one end (bed number one) and go around and see almost all the patients in the ward. At that time I felt most of the final year students were already at housemen level of proficiency. It would not have been impossible to see all the patients if we spared a bit more time.
The third year students of course, had yet to make that transformation, especially if its the first group who are making the transition from the non or pre-clinical years to the clinical years.
The first group of third years I had were actually pretty good. They were almost fourth year because it was their last clinical rotation for third year. Again, we could have seen most patients with this group, however, the learning outcomes are slightly different so I decided to take it down a notch as there were some students who could not keep up with the pace.
In the end, the third year students in general saw one patient and presented one case every day. That’s right, EVERY DAY. That’s how they became good at it.
So this is my tip no 1 for all internal medicine students, whether you are third, fourth or final year, see one long case per day & present it. I know that not all medical schools allow each student to present everyday. That doesn’t mean that you can’t present to your colleagues or the houseman or your cat. Practice makes perfect.
Tip n02. Regardless of what case you see, even of the physical examination is completely normal, use the opportunity (with the patients permission of course) to practice your physical examination skills.
Example, patient came in with abdominal pain, vomiting and diarrhoea, straightforward acute gastroenteritis, has been rehydrated and is awaiting discharge. You took the history and examined the patient. Boring, nothing exciting about the case at all. Just take out your patella hammer and ask if you can practice checking the reflexes. Ask if you can percuss the lungs. Look at the JVP and practice the hepato-jugular reflux. Dont do it all in one patient (unless they ABSOLUTELY INSIST). One extra physical examination facet just to polish your skills daily is priceless in the end. Examining a lot of patients who are ‘normal’ should allow you to pick up the ‘abnormal’ very quickly.
It kills me inside when I ask a student “what is the haemoglobin level?” and they look at me like I’m talking Greek. This is bedside teaching, not the exams, you must look at everything. The medical chart, nurses notes, observation chart, drug chart, lab results, ECG, Chest x-ray, scans, EVERYTHING.
No, you are not expected to remember every single detail but at least have the important and relevant information easily retrievable.
If you had looked at the chest x-ray earlier and are not sure of something, this is a good time to ask and discuss it.
When you’re at home, read up and around the topics of the case/s you had seen earlier on the ward. For example, if you saw a patient with atrial fibrillation, read up on:
The definition (just one or two lines is enough)
Symptoms and signs
Epidemiology – how common is this condition? The more common it is, the more likely you will encounter it in the exam and the more you are expected to know of it compared to conditions which are rare.
Differential diagnoses – its good to be able to list two or three
Investigations – what tests would you do, which are diagnostic, what do you expect to find, how results change management
Treatment – Always start with non-pharmacological followed by pharmacological expect in emergencies
Ok, time to put baby to sleep.
Hope this helps.